From the Editor
“Many People Taking Antidepressants Discover They Cannot Quit.”
The New York Times. Front page. Sunday edition.
One of the most read newspapers in the world just ran a story suggesting that antidepressants may be linked to significant withdrawal symptoms. That news article is, well, news. Journalists Benedict Carey and Robert Gebeloff interview a mother of four who says, “Had I been told the risks of trying to come off this drug, I never would have started it.”
Antidepressants: small pills but big problem?
This week’s Reading looks at the big article and considers its big implications.
Antidepressants and Withdrawal
“Many People Taking Antidepressants Discover They Cannot Quit”
Benedict Carey and Robert Gebeloff
The New York Times, 8 April 2018
Victoria Toline would hunch over the kitchen table, steady her hands and draw a bead of liquid from a vial with a small dropper. It was a delicate operation that had become a daily routine — extracting ever tinier doses of the antidepressant she had taken for three years, on and off, and was desperately trying to quit.
‘Basically that’s all I have been doing — dealing with the dizziness, the confusion, the fatigue, all the symptoms of withdrawal,’ said Ms. Toline, 27, of Tacoma, Wash. It took nine months to wean herself from the drug, Zoloft, by taking increasingly smaller doses.
‘I couldn’t finish my college degree,’ she said. ‘Only now am I feeling well enough to try to re-enter society and go back to work…’
Nearly 25 million adults, like Ms. Toline, have been on antidepressants for at least two years, a 60 percent increase since 2010.
The drugs have helped millions of people ease depression and anxiety, and are widely regarded as milestones in psychiatric treatment. Many, perhaps most, people stop the medications without significant trouble. But the rise in longtime use is also the result of an unanticipated and growing problem: Many who try to quit say they cannot because of withdrawal symptoms they were never warned about.
Reporters Carey and Gebeloff note the increase in use and long-term use of antidepressants:
- “Long-term use of antidepressants is surging in the United States, according to a new analysis of federal data by The New York Times. Some 15.5 million Americans have been taking the medications for at least five years. The rate has almost doubled since 2010, and more than tripled since 2000.”
- “Prescription rates have doubled over the past decade in Britain, where health officials in January began a nationwide review of prescription drug dependence and withdrawal.”
But is quitting antidepressants problematic? The article includes comments by patients who report significant problems. One is a British psychiatrist who notes confusion, light-headedness and “brain zaps” when he tried to stop.
The authors also review some studies:
- “In a recent survey of 250 long-term users of psychiatric drugs— most commonly antidepressants — about half who wound down their prescriptions rated the withdrawal as severe. Nearly half who tried to quit could not do so because of these symptoms.”
- “In another study of 180 longtime antidepressant users, withdrawal symptoms were reported by more than 130. Almost half said they felt addicted to antidepressants.”
- They mention the work of McMaster University’s Dr. Dee Mangin, a family physician, who has recently done a double-blind RCT involving 250 people in three cities who were on antidepressants long term. In the study, half had a tapering regiment, with less and less active antidepressant in the capsules they received; the other half were told that the medication was declining in dose, but it wasn’t. The patients were followed for 18 months. Though the data is now being analyzed, Dr. Mangin comments that some people had withdrawal symptoms so severe that they couldn’t quit.
A few thoughts:
- This is a news article that will be widely discussed – by clinicians, by policymakers, and, yes, by your patients.
- On this, we can all agree: while Health Canada and the FDA have high standards for drug approval, little work is done on following the long-term effects of drugs once they are approved. (A current FDA official told that me that one staffer reads through letters to the editor of prominent journals because so few physicians contact the FDA directly about post-approval problems.)
- Is this our Vioxx moment? Vioxx, you will recall, was a medication that showed itself to be highly problematic – linked to cardiac events despite having sailed through approval.
- Dr. Peter Kramer – the author and psychiatrist, who is quoted in the Carey-Gebeloff article – makes several good points on Twitter. You can read them here: https://twitter.com/PeterDKramer/status/982976854113046528. I draw attention to his second tweet: “The studies discussed in detail include: an anonymous online survey, a survey by sufferers of their acquaintances, a study of abrupt discontinuation w 1-week follow-up, & an unpublished study of discontinuation over one month…” Dr. Mangin’s study sounds well designed – but the data is unpublished.
- Former American Psychiatric Association President Jeffrey Lieberman calls the article “misleading.”
- There is evidence that some patients have withdrawal symptoms. In terms of practice, some common-sense measures seem appropriate – discuss with patients the challenges of quitting antidepressants including withdrawal symptoms, taper the medications over time, consider strategies to reduce these symptoms (like using longer-acting SSRIs, such as Prozac).
- A handout for patients? I like the Harvard Health information on this topic. You can find it here: https://www.health.harvard.edu/diseases-and-conditions/going-off-antidepressants.
- By way of disclosure, I receive no funding from the pharmaceutical industry. The Reading of the Week series has no industry sponsorship. For the record, while I read the NYT article on Sunday, it didn’t change my prescribing habits.
- Antidepressants have been much in the news. At 1 pm EST today, several experts – including Dr. Benoit Mulsant, the Chair of the University of Toronto’s Department of Psychiatry – will be discussing the recent Lancet paper on the effectiveness of antidepressants. You can watch here: https://www.youtube.com/watch?v=y_C_bS8XvHk. (And the NYT article may come up.)
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.